Treatment Guideline Chart

Prostate cancer is the cancer that occurs in the male's prostate.

It is the most common cancer in men >50 years of age.

Signs and symptoms include weak urinary stream, polyuria, nocturia, hematuria, erectile dysfunction, pelvic pain, back pain, chest pain, lower extremity weakness or numbness and loss of bowel or bladder control.


Interstitial Prostate Brachytherapy

  • Implantation of small radioactive sources into the prostate gland
  • Recommended initial therapeutic strategy for patients with very low-risk prostate cancer with life expectancy of >20 years and low-risk prostate cancer with life expectancy of ≥10 years not suitable for active surveillance
    • Difficult to perform in patients with very small or very large prostates, bladder outlet obstruction symptoms, or previous transurethral resection of the prostate (TURP)
  • Recommended for patients with favorable intermediate-risk prostate cancer with life expectancy of ≥5 years 
  • Recommended for patients with unfavorable intermediate- to very high-risk prostate cancer when given in combination with EBRT and ADT
    • Showed improved biochemical control when given together with ADT and EBRT (45-50 Gy), but with more side effects 
  • Recommended doses:
    • 120 Gy (palladium)
    • 140 Gy (125I) with postoperative dosimetry

Low Dose-Rate Brachytherapy

  • Uses permanent low-energy seeds (Iodine-125, Palladium-103, Cesium-131) for implantation that delivers adequate doses
  • Recommended for patients with the following:
    • Stage T1b-T2a N0 M0
    • ISUP grade 1 with ≤50% biopsy cores involved or ISUP grade 2 with ≤33% biopsy cores involved
    • ≤10 ng/mL initial PSA level
    • <50 cm3 prostate volume International Prostatic Symptom Score (IPSS) ≤12 and urinary flow test result of>15 mL/min
  • May be given to low-risk patients without recent TURP 
  • May be given to patients with intermediate to high-risk together with external beam radiation therapy (EBRT)
  • Recommended dose:
    • Iodine-125: 145 Gy (110 Gy with 40-50 Gy EBRT)
    • Palladium-103: 125 Gy (90-100 Gy with 40-50 Gy EBRT)

High Dose-Rate Brachytherapy

  • Uses temporary radioactive sources (eg Iridium-192) inserted into different locations in the prostate gland
  • Recommended dose:
    • Monotherapy: 13.5 Gy x 2 fractions
    • With EBRT: 9.5-11.5 Gy x 2 fractions; 5.5-7.5 Gy x 3 fractions; 4-6 Gy x 4 fractions

External Beam Radiation Therapy (EBRT)

  • Recommended initial therapeutic strategy for patients with very low- to high-risk prostate cancer
  • Limited radiation fields are preferred over extended field radiotherapy for localized and locally advanced prostate cancer
  • May be given with or without ADT or with brachytherapy with or without ADT in patients with unfavorable intermediate risk
  • Recommended to be given concomitantly with ADT as initial therapy in patients with high or very high risk 
  • Localization of prostate with image-guided radiation therapy (IGRT) is necessary with either 3-dimensional conformal radiation therapy (3D-CRT) or intensity-modulated radiation therapy (IMRT) for reducing target margin and ensuring treatment accuracy
    • Dose-escalated IMRT with IGRT is the best available approach due to low toxicity
  • Recommended dose for patients with low-risk prostate cancer is 75.6-79.2 Gy; intermediate- to high-risk and metastatic prostate cancer is 81.0 Gy

Stereotactic Body Radiotherapy (SBRT)

  • Uses high conformal, high-dose radiation delivered precisely using imaging techniques
  • May be considered in patients with limited metastatic disease to the vertebra or paravertebral regions when ablation is to be achieved, oligometastatic progression to achieve progression-free survival, and in symptomatic patients with lesions in or immediately adjacent to a previously irradiated treatment field 
  • May be considered as an alternative to conventionally fractionated regimens or to EBRT in unfavorable intermediate- or high-risk patients when combined with ADT when EBRT is medically challenging

Proton Beam Therapy

  • Delivers less radiation to surrounding normal tissues thereby decreasing long-term treatment morbidity
  • Further studies are needed to prove the efficacy of proton therapy against prostate cancer and its superiority to photon-based radiation therapy

Radiopharmaceutical Therapy

  • Eg Radium-223 dichloride, ß-emitting agents (Strontium-89, Samarium-153)
  • Option for palliative treatment of patients with metastatic disease

Beta-Emitting Radioactive Agents

  • Eg Strontium-89 (Sr-89, 89Sr), Samarium-153 (Sm-153, 153Sm)
  • Used for palliative treatment of painful bone or widespread metastases that are not eligible for chemotherapy

Radium-223 dichloride

  • An alpha particle-emitting radioactive agent used for metastatic castration-resistant prostate cancer (CRPC) with symptomatic bone metastases but without visceral involvement
    • Studies have shown that patients given Radium-223 had better overall survival and time to appearance of symptomatic bone events than those given placebo

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